FORMAT PENGKAJIAN ASUHAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH

STIKES MUHAMMADIYAH PALEMBANG

Nama Mahasiswa :
Tempat Praktek :
Tanggal Praktek :
Pengkajian Dilakukan Tanggal................jam................WIB

1. Identitas Klien
Nama : No RM :
Usia : Tgl Masuk :
Jenis : Tgl Pengkajian :
Kelamin : Sumber Informasi :
Alamat : Keluarga Terdekat :
No Telepon : status :
Status : Alamat :
Agama : No Telepon :
Suku : Pendidikan :
Pekerjaan : Pekerjaan :
Lama : Bekerja :

2. Riwayat Kesehatan
a. Keluhan Utama (saat masuk RS)
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b. Keluhan utama (saat pengkajian)
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c. Riwayat Kesehatan Saat Ini
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d. Riwayat Kesehatan Terdahulu

1. Penyakit yang pernah dialami:
 a. Kecelakaan :
b. Operasi (jenis dan waktu):
c. Penyakit (kronis dan akut) :
d. Terakhir masuk RS :

2. Alergi (obat, makanan, plester, dsb)

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3. Imunisasi (tambahan; flu, pneumonia, tetanus, dll)

4. Kebisasaan
Jenis Frekuensi Jumlah Lamanya
a. Merokok : .. .. ..
b. Kopi : .. .. ..
c. Alkohol : .. .. ..
5. Obat-obatan yang digunakan
Jenis Lamanya Dosis
.. .. ..
.. .. ..

3. Riwayat Keluarga
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4. Catatan Penanganan Kasus (Dimulai saat pasien di rawat di ruang rawat sampai
pengambilan kasus kelolaan)
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5. Pengkajian Keperawatan (12 Domain NANDA)

Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data di bawah ini.
Gambarkan semua temuan abnormal secara objektif, gunakan kolom data tambahan bila
perlu.

1. Peningkatan Kesehatan
Pengetahuan tentang penyakit/perawatan:
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Masalah keperawatan:
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2. Nutrisi
a. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ),sianosis( ),labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
b. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ),
dll..................................................................................................

Kebutuhan Nutrisi dan Cairan

BB sebelum sakit: kg BB sakit: kg
Program Diit RS :
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air
minum:.....................................................
Intake Makanan :

Intake Cairan :
 c. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Data Tambahan :
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Masalah keperawatan:
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3. Eliminasi dan Pertukaran

a. BAK:
b. Warna:
c. Konsistensi:
d. Frekuensi: x/ hari
e. Urine Output : cc
f. Penggunaan Kateter:.............................................................................................
g. Vesika Urinaria: Membesar .....................Nyeri tekan............................
h. Gangguan; Anuaria ( ), Oliguria ( ), Retensi Uria ( ), nokturia ( ),
Inkontinensia Urin ( ), Poliuria ( ), Dysuria ( )

Jalan nafas: Sputum ( ), warna sputum ( )

konsisitensi:........................................
Batuk ( ) frekuensi:..............................
 Dada
Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada burung ( )
benjolan ( ), dll..
Paru-paru:
Inspeksi: RRx/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ), Amforik ( ), Cog Wheel Breath Sound (
) metamorphosing breath sound ( )
Suara Tambahan: Ronki ( ), pleural friction( )
Data Tambahan:
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Masalah keperawatan:
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4. Aktivitas/Istirahat
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat
tidur, dll):
Kebiasaan Tidur siang:......................................jam/hari
Skala Aktivitas:
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total
Persendian:
Nyeri Sendi ( ), pergerakan sendi:.......................
ROM ( Range Of Motion):

Kekuatan Otot :

Kelainan Otot:

Tonus/aktifitas
Aktif ( ) Tenang ( ) Letargi ( ) Kejang ( )
Menagis keras ( ) lemah ( ) melengking ( ), Sulit menangis ( )

Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Pat0logis :
Babinsky : + ( ), - ( )
Kernig : + ( ), - ( )
Brudzinsky : + ( ), - ( )
Reflek Fisiologis
Biceps : + ( ), - ( )
Triceps : + ( ), - ( )
Patella : + ( ), - ( )

Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )

Mandi:...................x/mnt
Sikat gigi :........................................x/mnt
Ganti Pakaian :..................................x/mnt
Memotong kuku:...............................x/mnt
 DATA TAMBAHAN :
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Masalah keperawatan:
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5. Persepsi/Kognitif
Kesan Umum
Tampak Sakit: ringan ( ),sedang( ),berat ( ), pucat ( ), sesak ( ), kejang( )
1. Kepala
a. Fontanel anterior Lunak( ), Tegas( ), Datar( ), Menonjol( ),
Cekung( )
b. Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( )

2. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
reaksi terhadap cahaya: kanan Positif( ), negatif( ),kiri negatif( ) positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )

3. Bibir, Lidah
a. Bibir : normal ( ) sumbing ( )
b. Sumbing langit-langit/palatum ( )
c. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )

4. Telinga, Hidung, Tenggorok

a. Telinga: Normal ( )Abnormal ( ) Sekret( )
b. Hidung: Simetris ( )Asimetris ( ) Sekret ( ) Nafas cuping hidung ( )
c. Tenggorok: Tonsil( ), radang( )
 Data Tambahan
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Masalah keperawatan:
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6. Persepsi Diri
Perasaaan klien terhadap penyakit yang dideritanya .....................................................
Persepsi klien terhadap dirinya.......................................................................................
Konsep diri......................................................................................................................
Tingkat kecemasan.........................................................................................................
Citra Diri/Bodi image:.....................................................................................................
Data tambahan
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Masalah keperawatan:
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7. Peran Hubungan
Budaya:
Suku:
Agama yang di anut:
Bahasa yang digunakan :
Masalah sosial yang penting:
Hubungan dengan orang tua:
Hubungan dengan saudara kandung:
Hubungan dengan lingkungan sekitar
 Data Tambahan
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Masalah keperawatan:
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8. Seksualitas Dan Reproduksi

Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )

Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Riwayat kehamilan dan kelahiran :

Data Tambahan
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Masalah keperawatan:
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9. Toleransi/Koping Stress
GCS :.......
E:........................................................................................
V: .......................................................................................
M:.......................................................................................
 Data Tambahan:
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Masalah keperawatan:
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10. Prinsip Hidup

Budaya :
Budaya yang diikuti pasien dengan aktifitasnya
Masalah terkait budaya
Spritual / Religius :
Aktifitas ibadah dan kegiatan keagamaan yang biasa
dilakukan sehari-hari
Aktifitas ibadah dan kegiatan keagamaan yang
sekarang tidak dapat dilaksanakan
Perasaan pasien akibat tidak dapat melaksanakan hal
tersebut
Upaya pasien mengaasi perasaan tersebut
Keyakinan pasien tentang peristiwa/masalah kesehatan
yang sekarang sedang dialami
Psikologis :
Perasaan pasien setelah mengalami masalah ini
Cara mengatasi perasaan tersebut
Rencana pasien setelah masalahnya terselesaikan
Jika rencana ini tidak dapat dilaksanakan
Pengetahuan pasien tentang masalah/penyakit yang ada
Sosial :
Aktifitas/peran pasien di masyarakat
Masalah social
 Data Tambahan
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Masalah keperawatan:
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11. Keselamatan / Perlindungan

Tingkat Kesadaran : Composmentis ( ), Apatis ( ), Somnolen ( ), Sopor (
),Soporocoma ( ) Coma ( )
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg, RR..........x/min
Warna kulit :
Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ), oedema (
),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( )
Turgor Kulit: elastis ( ), tidak elastis ( )
Data Tambahan
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 Masalah keperawatan:
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12. Kenyamanan
Provaiking :
Quality :
Regio :
Scala :
Time :

Data Tambahan:
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Masalah keperawatan:
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Terapi
Tanggal Terapi :
Cara Golongan Kontra
No Nama Terapi Dosis Indikasi
Pemberian Obat Indikasi

Pemeriksaan Penunjang :
Laboratorium ( Tanggal Pemeriksaan )
USG ( Tanggal Pemeriksaan )
EKG ( Tanggal Pemeriksaan )
Rontsen ( Tanggal Pemeriksaan )
EEG ( Tanggal Pemeriksaan )
Dll.....